Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 44 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR ADULTS
Section 471-44-003 - LEVEL OF CARE
Universal Citation: 471 NE Admin Rules and Regs ch 44 ยง 003
Current through September 17, 2024
003.01 NURSING FACILITY LEVEL OF CARE (NF LOC) CRITERIA. The person or his or her legal representative must provide information needed to determine nursing facility level of care (NF LOC). In order to make a determination, the person or representative must be addressed on the basis of activities of daily living (ADL), risk factors, medical conditions and interventions, and cognitive function, to be determined via discussion and observation of the person; reports from caregivers, family, and providers; and current medical records.
003.01(A)
LEVEL OF CARE DETERMINATION FOR ADULTS AGE 18 OR
OLDER. A person must satisfy one of the four following categories
to meet nursing facility level of care (NF LOC) eligibility:
(1) A limitation in at least three activities
of daily living (ADL) and one or more risk factors;
(2) A limitation in at least three activities
of daily living (ADL) and one or more medical conditions and
treatments;
(3) A limitation in at
least three activities of daily living (ADL) and one or more areas of cognitive
limitation; or
(4) A limitation in
at least one activity of daily living (ADL) and at least one risk factor and at
least one area of cognitive limitation.
003.01(A)(i)
ACTIVITIES OF DAILY
LIVING (ADL). Information about limitations in activities of daily
living (ADL) is obtained from observation of the person in the home setting,
reports from guardians or caregivers, current medical records, school records,
and standardized assessments. Activities in daily living (ADL) are considered a
limitation when the person, due to their physical disabilities, requires
physical assistance from another person on a daily basis, or supervision,
monitoring, or direction to complete the tasks associated with each activity of
daily living (ADL) defined in this section. For the purposes of this section,
the term "ability" must be interpreted to include the physical ability,
cognitive ability, and endurance necessary to complete identified activities.
The following activities of daily living (ADL) are considered for nursing
facility level of care (NF LOC) eligibility:
(1) Bathing;
(2) Continence;
(3) Dressing or grooming;
(4) Eating;
(5) Mobility;
(6) Toileting; and
(7) Transferring.
003.01(A)(ii)
RISK
FACTORS. Risk factors must cause significant impact to the
person's life and functional abilities and require significant intervention in
a timely manner. Risk factors to be considered are:
(1)
Behavior: The
inability to act on one's own behalf, including but not limited to lack of
interest or motivation to eat, not taking medications, not caring for one's
self, not maintaining personal safety, wandering, avoiding social activities,
and relating to others in a socially-inappropriate manner;
(2)
Frailty: The
inability to function independently without the presence of a support person,
including but not limited to mismanaging finances or using poor judgment in
understanding abilities and health factors to safeguard wellbeing and avoid
inappropriate safety risk such as risk of falling; and
(3)
Safety: The lack
of adequate housing, including the absence of home modification or adaptive
equipment to assure safety and accessibility, the lack of a formal or informal
support system, or presence of abuse, neglect, or exploitation in the
home.
003.01(A)(iii)
MEDICAL CONDITIONS AND TREATMENTS. Medical conditions
and treatments to be considered are:
(1) A
medical condition is present which requires observation and assessment to
evaluate the person's need for treatment modification or additional medical
procedures to prevent destabilization when a person has demonstrated an
inability to self-observe or evaluate the need to contact skilled medical
professionals;
(2) Due to the
complexity created by multiple, interrelated medical conditions, there exists
potential for the person's medical condition to be unstable; and
(3) The person requires at least one ongoing
medical or nursing service.
003.01(A)(iv)
COGNITIVE
FUNCTION. Limitations in cognitive function to be considered are:
(1)
Memory: Lack of
short-term recall, unable to perform all or almost all steps in a multitask
sequence without cues, inability to recognize frequently encountered
caregivers' names or faces or know location of regularly visited places in
residential setting;
(2)
Orientation: Easily distracted, episodes of
disorganized speech, or variation in mental function over the course of a day;
behavior must be inconsistent with usual functioning;
(3)
Communication:
Inability to make oneself understood, including inability to express
information content, both verbal and nonverbal, or the inability to understand
information conveyed;
(4)
Judgment: Inability to independently make decisions
regarding tasks of daily life, except in new situations with only some
difficulty; and
(5)
Dementia: Dementia diagnosis, including Alzheimer's
disease.
003.02 PERSONS ELIGIBLE. A Level of Care (LOC) determination will be completed when a person is:
(1) Determined to be
eligible for Medicaid, or is under consideration for Medicaid eligibility;
and
(2) Requesting Medicaid funding
to cover nursing facility (NF) service or Home and Community-Based Waiver
Services for Aged Persons or Adults or Children with Disabilities.
003.02(A)
SPECIAL CIRCUMSTANCES
NOT EVALUATED OR SCREENED. Level of care (LOC) will not be
evaluated or reevaluated for Medicaid recipients who:
(i) Have previously been determined to meet
nursing facility level of care (NF LOC) and return to the same nursing facility
(NF) after discharge to a hospital, other nursing facility (NF), or swing bed.
This exception does not apply for persons who have previously been discharged
to an alternative level of care, or to the community;
(ii) Are Medicaid-eligible persons who admit
to the nursing facility (NF) under hospice care;
(iii) Are nursing facility (NF) residents who
elect hospice upon becoming Medicaid eligible;
(iv) Are receiving nursing facility (NF) care
which is currently being paid by Medicare;
(v) Direct transfer from one nursing facility
(NF) to another nursing facility (NF);
(vi) Have a preadmission screening and
resident review (PASRR) Level II level of care (LOC) determination indicating
the resident meets nursing facility level of care (NF LOC);
(vii) Are currently, or were previously
eligible the month prior to nursing facility (NF) admission, for the Aged and
Disabled Waiver program through the Department;
(viii) Are admitted to a special needs
nursing facility (NF) unit;
(ix)
Are currently eligible for the Program of All-Inclusive Care for the Elderly
(PACE) through the Department; or
(x) Are seeking out-of-state nursing facility
(NF) admission.
003.02(B)
EVALUATION
FORMAT. Evaluations will be conducted using common evaluation
tools. The evaluation tools reflect each area of nursing facility level of care
(NF LOC) criteria, the amount of assistance required and the complexity of the
care.
003.02(C)
REFERRAL.
003.02(C)(i)
MINIMUM REFERRAL
INFORMATION. The following is the minimum information required to
process a referral for level of care (LOC) determination:
(1) The name, position, and telephone number
of the person making the referral;
(2) The name of the nursing facility (NF)
involved, if different than the referral source;
(3) The name, date of birth, and social
security number of the person to be evaluated; and
(4) The date and time the referral is being
made.
003.02(C)(ii)
RECEIVING REFERRALS. When the Department or its agent
receives a referral to evaluate an applicant for admission to a nursing
facility (NF), they will begin to collect the information and supporting
documentation established in the evaluation tool. Information may be collected
either in person or through telephone interviews. Based on the information
gathered through the evaluation, the Department determines whether the
applicant meets nursing facility level of care (NF LOC) criteria.
003.02(C)(iii)
APPLICABLE TIME
FRAMES. A referral will only be accepted if it is verified by the
Department that an application has been received and is under consideration or
if an individual is determined eligible for Medicaid. The Department must
complete a level of care (LOC) evaluation within forty-eight (48) hours. If the
evaluation is not completed by the Department within forty-eight (48) hours,
the applicant for admission must be deemed by the Department to be appropriate
for admission until a level of care (LOC) determination is completed and any
required notice is given.
003.02(C)(iii)(1)
RETROACTIVE MEDICAID LEVEL OF CARE (LOC)
DETERMINATION. If a current nursing facility (NF) resident applies
for Medicaid without informing the nursing facility (NF) and a level of care
(LOC) referral is not completed during the Medicaid eligibility consideration
period, the nursing facility (NF) must make an immediate referral to the
Department when information is received that Medicaid has been approved. If the
following conditions are met, Medicaid coverage will be retroactive to the date
of Medicaid eligibility:
(a) The nursing
facility (NF) has in place a process to inform private pay clients and their
families that the nursing facility (NF) must be informed when a Medicaid
application is made;
(b) The
nursing facility (NF) makes a referral to the Department immediately upon
receipt of information about the opening of the Medicaid case. At the time of
this referral, the nursing facility (NF) must provide information on the date
and means by which information about Medicaid eligibility was obtained;
and
(c) The resident meets the
nursing facility level of care (NF LOC) criteria.
003.02(C)(iii)(2)
LEVEL OF CARE
(LOC) REFERRAL 14-DAY POST-MEDICAID DETERMINATION. A level of care
(LOC) approval determination will be effective as of the date of Medicaid
eligibility if the referral is completed by the 14th
calendar day following the Medicaid eligibility determination date.
003.02(C)(iii)(3)
REFERRAL AFTER
DEATH OR DISCHARGE. A level of care (LOC) referral will also be
accepted and a medical records-based level of care (LOC) determination will be
completed if Medicaid eligibility is not approved until after the person dies
or is discharged from the facility. To qualify, the referral must be completed
within 14 days of the Medicaid eligibility determination date, and the person
must meet level of care (LOC) criteria. If the required conditions are met, the
level of care (LOC) determination will be effective to the date of Medicaid
eligibility.
003.02(C)(iii)(4)
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) LEVEL OF CARE
(LOC) DETERMINATION. A Program of All-inclusive Care for the
Elderly (PACE) level of care (LOC) determination may be used to substantiate
nursing facility level of care (NF LOC) in the following cases:
(a) A Program of All-inclusive Care for the
Elderly (PACE) recipient immediately admits to, or already resides in, a
nursing facility (NF) following their disenrollment from the Program of
All-inclusive Care for the Elderly (PACE); or
(b) A Program of All-inclusive Care for the
Elderly (PACE) recipient admits to a nursing facility (NF) the month after
disenrollment from the Program of All-inclusive Care for the Elderly
(PACE).
003.02(C)(iii)(5)
DETERMINATION
OTHERWISE REQUIRED. A level of care (LOC) determination will be
required in all other cases for nursing facility (NF) admission.
003.02(D)
OUTCOMES OF THE EVALUATION.
003.02(D)(i)
NURSING FACILITY
LEVEL OF CARE (NF LOC) MET. If the Department determines that the
applicant meets nursing facility level of care (NF LOC) criteria and the person
chooses to receive nursing facility (NF) services, the Department will make
appropriate notifications.
003.02(D)(ii)
NURSING FACILITY
LEVEL OF CARE (NF LOC) NOT MET. If the Department determines that
the applicant does not meet nursing facility level of care (NF LOC),
notification of the determination is issued to the applicant, the facility, and
the managed care organization. Persons who are found to be ineligible for
Medicaid reimbursement for nursing facility (NF) services will be sent a notice
of denial by the Department.
003.02(D)(iii)
POSSIBLE
OPTIONS. Medicaid payment for nursing facility (NF) services will
only be available to those persons who are determined to require nursing
facility level of care (NF LOC). They will have the option of entering a
nursing facility (NF) or exploring home and community-based care services. If
the evaluation determines that there is a need for post-hospitalization
rehabilitative or convalescent care, the Department may indicate that
short-term or time-limited nursing facility (NF) care is medically necessary.
Prior to the end of the short-term or time-limited stay, the nursing facility
(NF) must contact Medicaid to review the person's condition and determine
future nursing facility level of care (NF LOC).
003.02(E)
NOTICES AND
APPEALS.
003.02(E)(i)
LEVEL OF CARE (LOC) DETERMINATION NOTIFICATION.
Medicaid staff send notification to each person, family, or applicable parties,
to inform the person of the level of care (LOC) decision. Nursing facility (NF)
residents with Medicaid funding, who no longer meet the criteria for nursing
facility level of care (NF LOC), must be allowed to remain in the facility up
to 30 days from the date of the notice.
003.02(E)(ii)
APPEALS. The person or his or her authorized
representative may appeal any action or inaction of the Department by following
standard Medicaid appeal procedures as defined in 465 NAC 6.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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